Rapid City Area School District 51-4

RAPID CITY AREA SCHOOL DISTRICT 51-4

Rapid City, South Dakota

- REQUEST FOR PROPOSAL -

GROUP MEDICAL, DENTAL AND BASIC LIFE/AD&D COVERAGE

RFP Issue Date: January 15, 2009

Proposal Due Date: March 2, 2009

Proposed Effective Date: September 1, 2009

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc TABLE OF CONTENTS

I. Introduction and Background

II. Current Plan Designs

III. Proposed Plan Designs

IV. Experience Data

V. Large Claims History

VI. Census

VII. Proposal Response Form

VIII. Proposal Specifications

IX. Proposed Performance Guarantees for Medical Plan

X. General Questionnaire

XI. Claims Administration Questionnaire

XII. Fully Insured Medical and Dental Plans Questionnaire

XIII. Medical Network Questionnaire

XIV. Utilization Management Questionnaire

XV. Disease Management Questionnaire (Optional)

XVI. Stop Loss Questionnaire

XVII. Prescription Drug Questionnaire

XVIII. Medical Network Analysis

XIX. Dental Plan Questionnaire

XX. Dental Network Section

XXI. Basic Life, AD&D and Dependent Life Insurance Questionnaire

XXII. Cost Exhibits

XXIII. Signature Page

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc APPENDICES

APPENDIX A Booklet: Group Health, Dental and Life Plans 2008 APPENDIX B Amendment 3 to the Medical Plan NOTE: Appendix A. The booklet serves as the Medical Plan Document. The 2008 booklet incorporates prior amendments. APPENDIX C Dental Contract APPENDIX D Life Contract APPENDIX E Medical Experience APPENDIX F Large Claims (Medical) NOTE: The large claims document is passworded. The password was included in the Invitation to Respond (ITR). Should you need the password, please contact Lori Bowen, Gallagher Benefit Services: [email protected]. APPENDIX G Dental Experience APPENDIX H Life Experience

CENSUS

Census – Active Employees (Medical, Dental, Life) Census – Retirees/COBRA (Medical) Census – Retirees/COBRA (Dental) Census – Retirees (Life)

NOTE: The census files are passworded. The password was included in the Invitation to Respond (ITR). Should you need the password, please contact Lori Bowen, Gallagher Benefit Services: [email protected].

EXHIBITS

EXHIBIT 1 Medical - Network Accessibility EXHIBIT 2 Medical - Major Hospitals EXHIBIT 3 Medical - Hospital Contracts Data EXHIBIT 4 Medical - Geo Access EXHIBIT 5 Medical - Network Analysis - Professional EXHIBIT 6 Medical - Disruption Analysis EXHIBIT 7 Dental - Network Accessibility EXHIBIT 8 Dental - Geo Accessibility EXHIBIT 9 Dental - Disruption Analysis EXHIBIT 10 Dental – Network Analysis EXHIBIT 11 Proposed Costs – Medical EXHIBIT 12 Proposed Costs – Dental EXHIBIT 13 Proposed Costs – Life EXHIBIT 14 Signature Page

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc I. INTRODUCTION AND BACKGROUND

A. Client’s name and address Rapid City Area School District 51-4 300 Sixth Street Rapid City, SD 57701

B. Type of industry Public school district (K-12) and post secondary institute (Western Dakota Tech only)

C. Eligibility Refer to “Current Plan Designs.”

D. Contributions (medical, prescription drug, dental & life insurance)

Coverage is a package which includes health/dental/life.

Teachers with a minimum of 6/10  EE Only Coverage: District pays 100% of contract cost.  EE + Dependent Coverage: District contributes 75% of cost. Teachers with a 5/10 time contract  EE Only Coverage: EE & District each (18.75 hours) contribute 50% of cost.  EE + Dependent Coverage: District contributes 37.5% of cost. Husband and Wife both employees of  Only 1 EE will be enrolled in the program District and the District will pay 100% of the cots for the EE and dependent coverage and the additional premium for $10,000 of additional life insurance for the spouse enrolled as a dependent. Retirees (up to age 65)  Medical & Dental: Retiree pays 100% of cost.  Life: Retiree pays 100% of cost.

E. Reason(s) for soliciting proposals / goals and objectives of marketing  Plans are primarily being marketed to determine the competitiveness of current arrangements.  The School District is also interested in looking at both fully insured and self-funded arrangements for both the medical and dental plans.  The medical/Rx plan is currently self-funded.  The dental plan is currently fully insured.

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc  The School District is seeking proposals only from vendors with established medical/Rx provider networks in Rapid City, South Dakota, as well as out-of-area networks.

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc F. Coverages available for quotation

1. Medical/Prescription Drug Coverage

a) Self-funded Medical/Rx Plans Proposals will be accepted from ASO carriers and qualified TPAs capable of offering the following services on a bundled basis:

 Claims administration  Stop loss insurance  Quote both individual and aggregate stop loss  Limit your response to one (1) stop loss carrier only  Provider network (in and out of state)  Pharmacy benefit manager (prescription drug coverage)  PBM proposals must be available on a stand-alone basis in the event the District elects to unbundle PBM services  Utilization management  Communication materials (including plan document and booklet/SPD)

NOTES:  ONLY bundled proposals will be accepted.  COBRA and HIPAA notifications are handled internally by the School District’s HR/Benefits Department. Do not provide a quote for these services.

b) Fully Insured Medical/Rx Plans

c) Disease Management (DM) DM can be quoted as an optional program for both the fully insured (if not included as part of the medical plan) and bundled self-funded proposals.

The School District may or may not elect a disease management program during this marketing process.

2. Dental Coverage

a) Self-funded Dental Plans

b) Fully insured Dental Plans

3. Basic Life and AD&D Insurance (to include basic dependent life insurance) Provide a quote for fully insured, non-contributory basic life and AD&D insurance (to include basic dependent life insurance).

G. Contract / plan year Contract Year September 1 through August 31 Plan Year Benefits run on a calendar year basis

H. Proposed effective date September 1, 2009

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc I. Contract term The contract term is for one (1) year. Every July the School District reviews, agrees upon (if satisfactory) and signs a new contract.

J. Schedule of events

The schedule for submission and review of the proposal is as follows:

RFP release & Invitation to Respond 1/15/2009 (ITR) Vendors to return ITR form 1/22/2009 Deadline for written questions 2/2/2009 Responses to questions posted to 2/9/2009 website Proposal due date 3/2/2009 Finalist interviews, if necessary Approximately the week of 4/13 or 4/20/2009 Best & Final, if required TBD Coverage effective date 9/1/2009

K. Proposal due date No later than 4:00 PM Mountain Time on March 2, 2009.

L. Items of Note 1. You MUST currently have a medical/Rx provider network in Rapid City, SD. If not, please do NOT provide a proposal, as it will not be considered. If this is the case, please provide notification of your declination. 2. Proposals will NOT be accepted after the proposal deadline. 3. There will not be a Bidder’s Conference. 4. “Best and Final” offers may be requested. 5. The client reserves the right to hold finalist interviews.

M. Proposal Contents In order for your proposal to be considered, you MUST complete the following sections of the RFP, as presented. Do NOT alter the forms / questionnaires, but complete them as provided. 1. Proposal Response Form 2. Proposal Specifications 3. All Questionnaires 4. All Exhibits applicable to the coverages being quoted.  Note: Exhibits 3, 6 and 10 should be sent to Gallagher Benefit Services ONLY; they should not be sent to the School District.  Exhibits must be completed in their entirety and in the format requested. 5. Signature Page. (Deviations from the specifications must be clearly noted on the signature page. Failure to note deviations may exclude the proposal from further consideration.) N. Compensation / Commissions Commissions may be included in the quoted premiums/rates; however, they must be fully disclosed including all overrides, contingencies and service fees.

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc O. Premium Tax Required in South Dakota.

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc P. Vendor Questions Questions must be submitted, in writing only, no later than 4:00 PM Mountain Time on February 2, 2009 to - William F. Robinson, Jr. Senior Area Vice President Gallagher Benefit Services, Inc. [email protected]

Do NOT contact the client with questions.

Q. Number and format of proposals 1. Submit an electronic version (preferably CD-ROM) of the proposal to -

William F. Robinson, Jr. Senior Area Vice President Gallagher Benefit Services, Inc. [email protected]

- AND -

Dave Janak Director of Finance, Budget & Community Development [email protected] Rapid City Area School District

2. Submit two (2) sets of the hard copy proposal to –

William F. Robinson, Jr. Senior Area Vice President Gallagher Benefit Services, Inc. 6399 South Fiddler’s Green Circle, Suite 200 Greenwood Village, CO 80111

R. Evaluation criteria Proposals will be scored according to the criteria outlined below:

1. Organizational strength 2. Client management team 3. Strength of local client service team 4. Strength and costs of provider network 5. Administration costs/premiums, including guarantees 6. Organization, quality and presentation of proposal 7. Finalist interviews (if applicable) 8. Local and regional references

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc S. Declinations Should you choose not to provide a quotation on this group, notify Bill Robinson at Gallagher Benefit Services, via e-mail (address above), no later than the proposal deadline. We value your response.

Much effort has been made to provide all necessary and accurate information. It is the sole responsibility of the proposers to ensure that they have all information necessary to complete submission of their proposals. If more information is needed, please contact the individual listed above.

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc II. CURRENT PLAN DESIGNS

MEDICAL PLAN

FUNDING: Self-funded

ADMINISTRATOR: First Administrators, Inc.

STOP LOSS CARRIER: Wellmark, Inc. since 9/1/07 (previously, United of Omaha)

PPO NETWORK: In SD & IA:  SelectFirstTM

Outside SD &/or IA:  Beech Street Network  Private Healthcare Systems, Inc.

UTILIZATION REVIEW: OHARA (Sioux Falls, SD)

PBM: Medco Health

PLAN TYPE: PPO Plan

CONTRACT YEAR: September 1 through August 31

PLAN YEAR: Benefits run on a calendar year basis

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc ELIGIBILITY: Active Employees  All individuals employed by the Rapid City Area School District who qualify for participation in the South Dakota Retirement System are eligible.  Any exception to the South Dakota Retirement System interpretation requires Rapid City Area School District Board approval on an individual classification named exception which includes, but is not limited to, retirees and school board members. Retirees  A continuation of benefits may be purchased after Early Retirement by Plan participants who are currently participating in the group plan, who qualify for retirement per their specific negotiated agreement, and who have qualified for retirement benefits in the South Dakota Retirement System.  Such continuation terminates at age 65 or when the retiree becomes eligible for Medicare due to age.  If at the time the retiree becomes eligible for Medicare and has dependent(s) not eligible for Medicare, those dependents may be continued under this plan.  Such continuation may be purchased by the spouse of a retiree after the retiree’s coverage terminates until the spouse is eligible for Medicare due to age.  Such continuation may be purchased by the dependent (other than spouse) of a retiree after the retiree’s coverage terminates for a maximum of 36 months or until the dependent reaches age 65 or is eligible for Medicare, whichever is shorter.  If the retiree participant dies and the spouse remarries, the new spouse and any newly acquired dependents will not be eligible for coverage under the plan. Medicare Retirees Not eligible. Coverage terminates at age 65 or when retiree becomes eligible for Medicare due to age. Spouse Legally married spouse, as determined and defined by the laws of the state of the covered participant’s residence. Dependent Children  Unmarried children (natural, stepchildren, legally (Health Only) adopted, foster, legal guardianship) of the participant or spouse who are dependent upon the participant for support.  Eligible until (a) marriage, (b) attain limiting age, (c) receive less than 50% of financial support from the parent participant or spouse and who is not claimed on the parent participant or spouse income tax return as a dependent.  Covered to age 19, unless a full-time student.  Full-time students who reach age 24 prior to 7/1/2007: Coverage continues to age 25.  Full-time students who reach age 24 on or after 7/1/2007: Coverage continues to age 29.

COVERAGE EFFECTIVE DATE: Coverage is effective on the first date of employment.

TERMINATION DATE:

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc  Coverage terminates the end of month following date of termination of employment or loss of eligibility, with an option to purchase continuation of benefits.  Retiree coverage terminates at age 65 or when the retiree becomes eligible for Medicare due to age.

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc BENEFIT SUMMARY: The following benefit summary is a VERY BASIC outline of benefits. For plan details, refer to the booklet; the booklet is available in electronic format and is posted on the website.

PPO Plan In-Network Out-of-Network General Plan Information Calendar Year Deductible $1,000 / $1,800 All benefits are subject to deductible unless otherwise noted Common Accident: When 2+ covered family members are injured in the same accident, only 1 deductible amount applies to eligible expenses resulting from that accident. Coinsurance 80% 60% Out-of-Pocket Max (Includes $3,000 / $5,800 $5,000 / $9,800 ded.) Lifetime Maximum $2,000,000 Dr. Office Visit/Exam 80% 60% Preventive Care Routine Physical Exams, Not covered Not covered Immunizations Mammograms 80% 60% Pap Test 80% 60% Prostate Cancer Screening 80% 60% Well-Child Care Not covered Not covered Psychological Care - Outpatient 80%; 26 visits per calendar 60%; 26 visits per calendar year year - Inpatient 80%; 60 days per calendar year 60%; 60 days per calendar year Alcohol / Chemical Dependency - Outpatient 80%; allowed at Max Allowable 60%; allowed at Max Allowable Fee Fee - Inpatient 80%; 30 days per 6-month 60%; 30 days per 6-month period, 90 days per life period, 90 days per life Emergency Room $50 copay, then 80% $50 copay, then 60% Copay does not accumulate toward satisfaction of the deductible or coinsurance limit. If visit is a result of an injury deductible and coinsurance will apply. Skilled Nursing Facility 80%; 60 days per confinement 60%; 60 days per confinement Inpatient Hospitalization 80%; pre-authorization required 60%; pre-authorization required - Pre-Auth. of Services Penalty for Non-Compliance: Eligible charges reduced by 25% Required up to a maximum of $250 for any single hospitalization Self-Audit Billing Credit 50% credit for provider billing errors found by participants. Maximum $500 per calendar year Prescription Drugs - Generic 20% copay; greater of 90 day-supply or 100 unit doses - Brand Name 30% copay; greater of 90 day-supply or 100 unit doses Other Outpatient Surgery 80% 60% Home Health 80% 60%

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc Hospice 80% 60% Chiropractic Care 80% 60%

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc STOP LOSS COVERAGE:

Individual Stop Loss Deductible $135,000 Max Individual Lifetime $2,000,000 Reimbursement Covered Benefits Medical and Rx Contract Basis 24/12 Aggregate Stop Loss ASL Coverage 125% of expected paid claims Minimum Aggregate Deductible $11,019,720 Covered Benefits Medical and Rx Contract Basis 24/12

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc DENTAL PLAN

FUNDING: Fully insured CARRIER: Delta Dental of South Dakota PLAN TYPE: Blind PPO CONTRACT YEAR: September 1 through August 31 PLAN YEAR: Benefits run on a calendar year basis ELIGIBILITY: Eligibility is the same as medical; coverage is a package (medical, dental, life). EFFECTIVE DATE: Coverage is effective on the first date of employment. TERMINATION DATE: Same as medical.

BENEFIT SUMMARY: The booklet is available in electronic format and is posted on the website. The contract is available in electronic format and is posted on the website.

DENTAL PLAN Dentists Can see Participating and/or Non-participating dentist Calendar Year Deductible $50 per person; $150 per family Basic Services  Diagnostic/Preve  Plan pays 100%, no deductible ntive Services  Plan base 80% after deductible  Ancillary  Plan pays 80% after deductible (emergency pain relief)  Plan pays 80% after deductible  Oral Surgery  Regular Restorative Dentistry Special Services  Endodontics  Plan base 80% after deductible  Periodontics  Plan base 80% after deductible  Special  Plan pays 80% after deductible Restorative Dentistry  Plan pays 50% after deductible  Prosthetics  Plan pays 50%, no deductible (Children  Orthodontics and Adults) Maximums  Dental Services  $1,500 per calendar year  Orthodontic  $1,500 per lifetime Services Pre-determination For special or basic services exceeding $350

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc  LIFE INSURANCE

FUNDING: Fully insured CARRIER: Pioneer Mutual Life Insurance Company CONTRACT YEAR: September 1 through August 31 ELIGIBILITY: Eligibility is the same as medical; coverage is a package (medical, dental, life). EFFECTIVE DATE: Coverage is effective on the first date of employment. TERMINATION DATE: Same as medical. (Dependent coverage terminates at the time of the employee’s retirement.) BENEFIT SUMMARY: The contract is available in electronic format and is posted on the website.

Employees Life AD&D Active Employees $10,000 $10,000 Retirees $5,000 $5,000 Age Reduction Benefits reduce 50% @ age 70 Living (Accelerated Death) Benefit 25% Waiver of Premium Included. Continuously disabled for at least 6 months. Prior to age 60. Conversion Included AD&D Benefit Schedule Loss Period Within 365 days of accident Life 100% Both hands, both feet or sight 100% both eyes One hand and one foot 100% One hand and sight of one eye 100% One foot and sight of one eye 100% Sight of one eye 50% One hand or one foot 50% Plegias, coma, etc. Not covered Dependents (of Employees Only) Life Insurance Only (No AD&D) Spouse $2,000 Children 14 days up to 6 months $100 6 months up to age 19 (to 25 for FTS) $1,000 Termination Dependent Life Insurance benefits terminate at the time of the EE’s retirement

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc III. PROPOSED PLAN DESIGNS

Please provide a quote for the following, as applicable.

A. SELF-FUNDED MEDICAL / RX PLAN (ASO/TPA SERVICES)

1. Provide a quote for bundled administration services.

Proposals will be accepted from ASO carriers and qualified TPAs capable of offering the following services on a bundled basis:  Claims administration  Stop loss insurance  Quote both individual and aggregate stop loss  NDPERS may or may not elect ASL coverage during this marketing process  Limit your response to one (1) stop loss carrier only  Provider network (in and out of state)  Pharmacy benefit manager (prescription drug coverage)  Utilization management  Communication materials (including plan document and booklet/SPD)

NOTE:  ONLY bundled proposals will be accepted.  COBRA administration and HIPAA notifications are currently handled internally by the School District’s HR/Benefits Department. Please provide a quote for these services as indicated in the Cost Exhibits.

2. Provide a quote for stop loss insurance as outlined below.

a) Individual Stop Loss – Provide a quote based upon the following parameters:  Contract Basis: 15/12  ISL Deductible(s): $135,000  Max ISL Reimbursement: $2,000,000 per member  Coverages: Medical and Rx b) Aggregate Stop Loss – Provide a quote based upon the following parameters:  Contract Basis: 15/12  ASL Coverage: 125% of expected paid claims  Max ASL Reimbursement: N/A  Coverages: Medical and Rx

NOTE: Provide quotes from one (1) stop loss carrier only.

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc B. FULLY INSURED MEDICAL PPO / RX PLAN

1. Provide a quote for the current plan design.

2. Provide the percentage impact to the premium to add and/or modify each of the following benefits:

a) Routine physicals (covered in-network only); ages 2+; 80% not subject to deductible. b) Well child care (covered in-network only); ages birth to 2 years; 80% not subject to deductible. c) Mammograms, pap tests, prostate cancer screenings - covered per AMA guidelines; 80% not subject to deductible. d) Change Rx plan to the following:

Retail (30 day supply) Mail Order (90 day supply) Generic 10% copay / $10 max $10 copay Brand formulary 20% copay / $40 max $40 copay Non-formulary 30% copay / $80 max $80 copay Specialty drugs 20% copay to $250 N/A maximum out-of-pocket per year. Mandatory specialty pharmacy.

NOTE:  Assume the current contribution structure. (Coverage is a package which includes health/dental/life.)  Assume the current tier structure.

C. SELF-FUNDED DENTAL PLANS

Provide a quote for bundled administration services.

Proposals will be accepted from ASO carriers and qualified TPAs capable of offering the following services on a bundled basis:  Claims administration  Provider network (in and out of state)  Communication materials (including plan document and booklet/SPD)

NOTE:  ONLY bundled proposals will be accepted.  COBRA administration and HIPAA notifications are currently handled internally by the School District’s HR/Benefits Department. Please provide a quote for these services as indicated in the Cost Exhibits.

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc D. FULLY INSURED DENTAL PLANS

Provide a quote for the current plan design.

NOTE:  Assume the current contribution structure. (Coverage is a package which includes health/dental/life.)  Assume the current tier structure.

E. FULLY INSURED BASIC LIFE AND AD&D

Provide a quote for the current plan design.

NOTE:  Assume the current contribution structure. (Coverage is a package which includes health/dental/life.)

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc IV. EXPERIENCE DATA

Refer to the separate pdf files.

V. LARGE CLAIMS HISTORY

Refer to the separate pdf file. NOTE: The large claims document is passworded. The password was included in the Invitation to Respond (ITR). Should you need the password, please contact Lori Bowen, Gallagher Benefit Services: [email protected].

VI. CENSUS

Refer to the separate Excel Workbooks.

NOTE: There are four (4) census workbooks as indicated below:  Census – Active Employees (Medical, Dental, Life)  Census – Retirees/COBRA (Medical)  Census – Retirees/COBRA (Dental)  Census – Retirees (Life)

NOTE: The census files are passworded. The password was included in the Invitation to Respond (ITR). Should you need the password, please contact Lori Bowen, Gallagher Benefit Services – [email protected].

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc VII. PROPOSAL RESPONSE FORM

VENDORS MUST COMPLETE THIS SECTION.

Please check (X) the box(es) for the coverages / services included in your proposal.

Medical Coverage Self-Funded * Fully Insured Duplicate current plan design Alternative benefit N/A – Does not impact fees options

* Limit stop loss quotes to one (1) stop loss carrier only.

Disease Included in medical Management Stand-alone plan (Optional)

Dental Coverage Self-Funded Fully Insured Duplicate current plan design

Basic Life and Fully Insured AD&D Duplicate current plan design

NOTE: Your typed name and date above will be considered a valid signature for this RFP.

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc VIII. PROPOSAL SPECIFICATIONS

The following are proposal specifications. Please complete the following chart by responding in the right-hand column. If you disagree with any of the criteria, you may not be considered.

1. The effective date of coverage is Agree Disagree acknowledged and accepted.

2. You must be licensed in South Dakota or Agree Disagree willing to obtain a license in South Dakota.

3. ASO and bundled TPA fees must be Agree Disagree guaranteed and level for a minimum of two (2) years from the effective date. Longer guarantees are encouraged.

4. Stop loss premiums must be guaranteed for a Agree Disagree minimum of one (1) year. A maximum second year rate increase is preferred.

5. Fully insured medical premiums must be Agree Disagree guaranteed for a minimum of one (1) year from the effective date. Longer guarantees are encouraged.

6. Fully insured dental and life premiums must Agree Disagree be guaranteed and level for a minimum of two (2) years from the effective date. Longer guarantees are encouraged.

7. Rates/premiums may include commissions. All Agree Disagree commissions, contingencies, overrides, service fees, etc. are fully disclosed on applicable rate pages. The client retains the right to audit disclosure compliance.

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc 8. Renewal rates must be submitted 180 days Agree Disagree (120 days for stop loss) prior to the contract renewal date.

9. Your proposal assumes that each line of Agree Disagree coverage is purchased on a stand-alone basis (except those that MUST be bundled). Provide information in the Cost Exhibits related to any savings or discounts applicable if your company is awarded two or more lines of coverage.

10. For self-funded proposals, your PBM proposal Agree Disagree is available on an unbundled basis and you agree to allow another PBM if selected by the District.

11. You have included detailed plan summaries for Agree Disagree all quoted plans.

12. You currently have a medical/Rx provider Agree Disagree network in Rapid City, SD.

13. You completed the self-funded network Agree Disagree analysis sections, in their entirety, in the format requested.

14. The vendor will be responsible for producing Agree Disagree the Summary Plan Description. The client reserves the right to review / revise the SPD prior to final printing.

15. Vendor agrees to provide an SPD draft within Agree Disagree 60 days of the effective date.

16. Vendor agrees to provide all standard reports Agree Disagree to the client and its professional advisor.

17. Insured coverage must be provided on a no- Agree Disagree loss / no-gain basis for all covered participants

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc so the current group does not suffer a loss of benefit solely due to the transfer of coverages to your firm.

18. You must agree to waive the “actively at Agree Disagree work” provision for the currently enrolled. The master contract will reflect the elimination of the actively at work restriction or deferred effective date for all initially enrolled active or inactive employees and dependents. This will include only initial eligibles (those eligible on the effective date of the contract) including COBRA continuees.

19. You are in compliance with all HIPAA Privacy Agree Disagree and Electronic Data Interface (EDI) and Security requirements.

20. You have reviewed and accept the Plan’s Agree Disagree eligibility provisions outlined in the RFP.

21. Your contract must require no more than a Agree Disagree 120-day notice of termination. Your contract cannot prohibit the group from terminating coverage at any time. There must be no penalties for late notification or for termination off anniversary.

22. Claims experience must be provided at least Agree Disagree quarterly, including each renewal to District and its advisor.

23. Vendor has specifically listed all deviations from Agree Disagree the RFP and coverage requirements on the Signature Page. NOTE: Deviations MUST be listed; vendors cannot simply make a “general” reference to the proposal.

24. You completed all questionnaires and exhibits in Agree Disagree full and in the format requested.

Note:  The GBS analysis to the School District will include only aggregated discount information;

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc it will not include provider-specific discount information.  In order to insure this, please send Exhibits 3, 5 and 10 only to Gallagher Benefit Services, Inc.; do not send these three (3) exhibits to the School District. All other exhibits should be sent to both GBS and the School District.  GBS is willing to sign a confidentiality agreement, if required. If this is the case, contact Bill Robinson at Gallagher Benefits Services as soon as possible.

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc IX. PROPOSED PERFORMANCE GUARANTEES FOR SELF-FUNDED MEDICAL PLAN

The following are the performance guarantees for claims administration.

Measurement Performance Frequency / Penalty Service Area Standard Definition Criteria Claims 95% The percentage of Quarterly, with 2% of Processing audited claims monthly reporting to quarterly Accuracy processed accurately. clients. Based on fee Calculated as the total randomly selected The medical number of audited statistical audit TPA / ASO claims processed sample results. carrier shall without any errors, accurately divided by the total process a number of audited designated claims. Definition of percent of the “error” includes any total claims type of error that has an processed. affect on the member or provider, e.g., incorrect explanations of benefits or payments. Each type of error is counted as one full error and no more than one error can be assigned to one claim.

Financial 99% The percentage of Quarterly, with 2% of Payment audited client claims monthly reporting to quarterly Accuracy dollars paid accurately. client. Based on fee Calculated as total randomly selected The medical audited paid dollars statistical audit TPA / ASO minus the absolute sample results. carrier shall value of over and correctly pay a underpayments (without designated offsetting one against percent of the the other) divided by total claim total audited paid dollars paid. dollars.

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc Turnaround  95% of The percentage of Quarterly, with 0.5% of time (TAT) clean claims processed within monthly reporting quarterly claims a specified number of by computer fee for The medical processed calendar days. TAT is generated report to each TPA / ASO and paid measured from the date client. category carrier shall within 21 the claim is received by (3) process a calendar Contractor to the date it designated or 15 is processed (i.e., paid, percent of business denied, or pended for claims it days. external information). receives within  98% of The day the claim is the following clean received will not be days. claims included in this processed calculation. and paid within 28 Business days will mean calendar the days of the week or 20 that the Claim Office is business open to conduct days. business, which excludes Saturdays, Sundays and holidays.

Number of days will be adjusted to reflect bank account funding delays.

 98% of Percentage of claims Quarterly, with investigat requiring internal monthly reporting to ed claims investigation and client. processed review. Exceptions to and paid be reported monthly to within 45 agencies. days.

Telephone Average The amount of time that Quarterly, with 1% of response time speed of elapses between the monthly reporting to quarterly (Applies to both answer time a call is received client of client- fee TPA and on-site within 30 into the phone system specific results. service seconds or to the time answered by representative) less a representative (live voice answer). Abandonment Not to Percentage of calls that Quarterly, with 1% of rate exceed 5% are unanswered calls monthly reporting to quarterly (i.e., caller hangs up) client of client- fee specific results.

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc Member  Respond Measured from date of Quarterly, with 1% of Appeals & to 90% of Appeals & Grievances monthly reporting to quarterly Grievance all written receipt to date response client of client- fee response member mailed to specific results. time (to to Client member/client. exclude Appeals & Resolution is defined as expedited Grievance a satisfactory result to medical s within 5 the member/client determination working within the parameters of requests). days after the plan specifications. To include UM receipt of and Non-UM inquiry. appeal cases. 98% within 15 days of receipt.

 95% of Resolution is defined as all Appeals closure of cases based & on benefit and evidence Grievance provided to s resolved member/client and within 30 committee reviewing days. cases. 98% of all Appeals & Grievance s inquiries resolved within 60 days.

ID card Within 10 The amount of time Quarterly 2% of turnaround working elapsed from the date of quarterly time days of receipt of eligibility fee receipt of information to the date the ID cards are mailed to eligibility members. information ID cards for “future” enrollees (reporting 30 days prior) will be mailed 14 business days prior to the effective date.

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc Report Monthly, Client and professional Monthly within 25 $250 per delivery quarter-to- advisor receipt. days following the late report date, year- end of the month. to client to-date paid and advisor claims and Quarterly reports lag reports within 45 days within 25 following the end of days the quarter. following end of reporting period.

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc X. GENERAL QUESTIONNAIRE

NOTE: THE QUESTIONS CONTAINED IN THIS SECTION ARE APPLICABLE TO ALL LINES OF COVERAGE.

A. FIRM / ORGANIZATION QUESTIONS

1. Provide a description of your organization, to include, at a minimum: parent company and location; quoting organization and location, if different; and subcontractors/partners, if any.

For each organization noted, provide:

 Date formed

 Ratings of company(s):  A.M. Best  Moody’s  Standard & Poor’s

 Where is your corporate headquarters located?

 Number of employees in your company.

 In-force number of South Dakota groups with greater than 500 active employees.  Medical  Dental  Life

2. In the past five (5) years, have you been acquired or been involved with any merger/acquisition? If yes, describe.

3. Provide a copy of your most recent annual financial statement, or other documentation reflecting financial performance.

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc 4. Do you carry an Errors & Omissions policy?

 What are the limits?

5. Do you carry a comprehensive general liability policy?

6. Does your company carry a fidelity bond?

7. Have claims been made against any of these policies within the past two years?

 If yes, describe.

8. Are you currently licensed in the state of South Yes No Dakota?

9. What customer service office will be responsible for this account? Provide the following:  Location of office.

 Size of office

 Days and hours of operation

 Will you provide a toll-free number?

10 What claims office will be responsible for this . account? Provide the following:  Location of office.

 Size of office

 Days and hours of operation

 Will you provide a toll-free number?

11 Who will be the primary liaison for the client?

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc  Where will they be based?

12 Provide a detailed implementation plan, including . action items and due dates. Include support for implementation and open enrollment.

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc 13 Will you agree to comply with the proposed medical . plan Performance Guarantee (as outlined in Section IX)?

If you are unable to comply with the proposed guarantees, provide your alternate proposal.

14 Provide samples of your standard employee . communication materials and forms with your proposal.

15 Please provide the following (South Dakota public . sector employers are preferred):

 Three (3) current client references  At least one of these references should be from a client of similar size. Provide -  Client Name  Contact  Address  Telephone number  Approximate # of employees covered by each contract  Type of coverage (e.g., medical, dental, life)

16 Please provide the following (South Dakota public . sector employers are preferred):

 One (1) former client, who may be contacted.  Provide -  Client Name  Contact  Address  Telephone number  Approximate # of employees covered by each contract  Type of coverage (e.g., medical, dental, life)  Reason for termination

B. IMPLEMENTATION, ENROLLMENT, ELIGIBILITY AND MAINTENANCE QUESTIONS

17 Do you require a deposit? .  If so, how much do you require?

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc 18 What mediums do you accept for plan enrollment? .

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc 19 Do you offer online eligibility maintenance for all . clients?

 If so, is there a charge?  Is there a charge for hard copy maintenance?

20 Explain your billing procedures. .  How frequently are clients billed?  What charges do the billings encompass?

C. GENERAL ADMINISTRATION QUESTIONS (NOTE: NOT ALL OF THE QUESTIONS ARE APPLICABLE TO LIFE INSURANCE; PLEASE ENTER “N/A” IN EACH OF THESE AREAS.)

21 For insured coverages: for the first and each . renewal year, what periods of time will be used as the basis for determining renewal recommendations?

22 Will you agree to submit to independent audits at . no expense to the client?

23 For insured plans, is evidence of insurability a . requirement under ANY part or parts of the plan proposed by your company?

 If yes, specify.

24 When are premiums/fees due under your policy? .  What is the grace period?

 If premium/fee is paid after the grace period, is a penalty and/or interest charge assessed?

 If yes, explain in detail.

 Are there any options available with respect to the grace period?

 If so, explain the option(s) and any charge that is made for them.

25 In the event this account produces a deficit in any Yes No . one year, will your company expect to recoup the

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc deficit?  If so, describe in detail proposed methodology / terms.

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc D. TECHNOLOGY QUESTIONS

26 Which of the following tasks can members and plan . sponsor representatives perform ONLINE? Members Plan Sponsors  Enrollment (New Hires and Open Enrollment)  Changes in Status  Billing (Plan Administrators only) -  Claim inquiry  Provider search  ID card request  Electronic EOB  Terminations  Access provider directories  Other

27 Is there an additional cost for online services? .

 If yes, describe.

28 Indicate if your claims system presently can auto- . adjudicate claims electronically, including the origination of electronic payments and credits.

 Include the name and owner of any leased systems or clearinghouses used.

29 What percentage of claims is auto-adjudicated . through your system?

30 Does your system support on-line, real-time . eligibility inquiries?

31 Does your system support on-line, real-time claim . status inquiries?

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc E. REPORTING QUESTIONS

32 Provide a list of all standard and optional reports . available and their costs (if any).

Additional Cost? Report Frequency If so, indicate Comments amount.

33 Does the client have the ability to access your . database in real time for purposes of:  Tracking plan experience Yes No

 Utilization patterns Yes No

 Other available plan information Yes No

 How is this ability provided?

 Is there an additional charge to the client?

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc XI. CLAIMS ADMINISTRATION QUESTIONNAIRE (SELF-FUNDED & INSURED MEDICAL & DENTAL PLANS)

A. SPECIFICATIONS

1. You must permit the employer to have access to all files on request (e.g., a claims audit). _____Agree _____Disagree

2. Run-out claims will be paid by the existing administrator. Your pricing should assume no run- _____Agree in claims payment. _____Disagree

B. FIRM / ORGANIZATION

3. How many trained examiners do you employ at this ______Examiners site?

 What is their average length of experience? ______Years

4. Show the number of employer groups you service in each of the size categories below:

 100 – 1,000 EEs (Nationally) ______ 500 – 2,000 EEs (South Dakota ONLY) ______

C. CLAIMS ADMINISTRATION SERVICES

5. Describe the options available to the group for submitting eligibility data.

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc 6. Do you maintain separate bank accounts for each _____ Yes ______No client?

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc 7. What claims adjudication system do you use? (If proprietary, describe the staffing and client response capabilities of your IT staff.)

 Is your system leased/owned?

 When was the system last updated?

8. Confirm in writing your ability to adjudicate the existing and alternative benefit plan(s).

 Which provisions would require manual intervention?

9. The client reserves the right to carve-out PBM Yes No services. Do you agree to this requirement?

(Applicable to ASO/TPA only.)

 Are you able to cover Rx under the stop loss in a carve-out situation? Yes No

 Do you charge a stop loss interface fee in a carve-out situation? Yes No

10 Identify and comment on any major claim / . eligibility / reporting system changes or upgrades planned in the next 12 to 24 months.

11 Describe the claims appeal process and associated . timeframes.

 Are there any additional fees associated with this process?  Provide a sample copy of the following in your proposal:  Denial of benefits (participant and employer).  Explanation of benefits or payment (participant and employer).

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc 12 What method and reimbursement level does . your firm utilize to determine Usual and Customary (HIAA, company profile, network contracted rates, RVS, etc.) for: a) South Dakota b) Out of state c) Out of network SD Out of Out of state netwo rk  HIAA or related data base:  Identify.  Percentage used?  Can the client select a different level? Yes No  Other

13 How often are allowances revised? Monthly . Quarterly Semi-annually Other (Describe)

14 Can your system accept electronic claims Yes No . submission?  What % of claims is submitted electronically?

15 Can your system detect unbundling of services? Yes No .

16 Can your system detect “code creeping”? Yes No .  If yes, what action do you take upon discovery?

17 Explain in detail your procedures for identification . and recovery of third party liability and coordination of benefits claims. For example:

 Do you outsource this service?

 Can the client retain its own legal counsel to provide this service?

 Will this impact fees?

 Does your claim system readily identify potential possible subrogation/COB

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc opportunities prior to claim payment?

 Do you pend and pursue or pay and pursue these types of claims?

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc 18 Who performs your Medical Reviews? .  Are they included in your fees?

 If not, what is the additional fee for this service?

19 Audits: .  What is the frequency of audits done by your internal staff?

 What is the frequency of audits done by external vendors?

 Who performs the external audits?

20 Would you be willing to allocate an allowance for Yes No . outside audits?

 If so, specify dollar allowance.

21 In the event of contract termination, how will you . process “run- out” claims:  Service not available

 A predetermined fee per claim processed

 A predetermined percentage of paid claims

 Duration of run-out claims adjudication  3 months  6 months  12 months  Other

22 Do you agree to provide the client and its actuary, Yes No . at no cost, all claims and eligibility data needed for it to comply with GASB 45?

 If not, please explain.

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc XII. FULLY INSURED MEDICAL / DENTAL PLANS QUESTIONNAIRE

1. How do you define a paid claim?

2. How do you establish reserves for incurred but not paid claims?

3. For the first year, what dollar amount of reserves would you establish

4. What interest rate is credited on the reserves?

5. What is your charge for a conversion policy?

6. Describe in detail all initial and renewal underwriting requirements:

 Initial  Renewal

7. Is your quote fully pooled or experience rated?

8. Does your quote assume the coverage is eligible Yes No for dividends?

9. MEDICAL ONLY. What is your medical pooling point?

 What options are available?

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc 10. Can additional premium be charged to the client Yes No as a result of year-end accounting or at termination?

 If yes, please explain under what circumstances this would occur.

11. In the event this account produces a deficit in any one year, how would your company expect to recoup the deficit?

12. How soon after the anniversary date are experience refunds available to the policyholder?

13. From what date is interest on the dividend credited?

14. Is the unused portion of the claim reserve Yes No returnable to the policyholder upon termination?

 If yes, at what date would the reserve be available what rate of interest would be credited?

 Will the reserve be returned regardless if termination is on or off the anniversary date.

15. Is a letter of credit required? Yes No

16. Is a form of premium stabilization fund required? Yes No

 If so, describe in detail.

17. What is your estimate of paid claims?  Year One  Year Two

18. Do you agree to provide the client and its Yes No actuary, at no cost, all claims and eligibility data Page 48 of 87

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc needed for it to comply with GASB 45?

XIII. MEDICAL NETWORK QUESTIONNAIRE

ALL MEDICAL VENDORS MUST COMPLETE THIS SECTION.

A. PPO PLANS

1. Has your PPO received NCQA / URAC Yes No accreditation? If yes …

 Which accreditation?

 When?

 For how long?

 When was your last review?

2. Does your PPO plan require a referral from the PCP to a specialist?

3. Does your PPO include the following:  Chiropractors Yes No  Ambulance Yes No  Home Health Care Yes No  Hospice Care Yes No  Alcohol Rehabilitation Yes No  Physician Assistants/Surgical Yes No Assistants

4. Will you accept the client’s current Yes No enrollment forms?

5. How are physicians reimbursed? Check ALL that apply: Salary Per Capita Discounted fee for service Page 49 of 87

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc Other (Describe)

 Is there any withhold on their Yes No payments?

 If yes, how and when is it to be paid to them?

6. How are providers reimbursed when the patient is referred outside the managed care network?

B. NETWORK QUESTIONS

7. For claims incurred out of your network service area, what hospital and physician discounts are available?

 If you use proprietary networks, please identify.

8. With regard to network directories, please respond to the following items. (NOTE: Do NOT include a provider directory with your proposal.)

 Is your directory available on the Internet on in a website?  If your provider directories are not available online, how frequently are directories distributed?  How are members, plan sponsors and providers notified of changes?

9. Do you own your South Dakota and out-of-state provider networks, or do you subcontract?

 If you subcontract, please identify networks.

10 Are you willing to add providers specifically . requested by the client?

11 Do participating network providers have a Page 50 of 87

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc contractual agreement not to “balance bill” the patient?

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc XIV. MEDICAL UTILIZATION MANAGEMENT QUESTIONNAIRE

ALL MEDICAL VENDORS MUST COMPLETE THIS SECTION.

A. GENERAL QUESTIONS

1. Indicate your UM Program accreditation:  URAC Yes No Effective date ______ NCQA Yes No Effective date ______ Other (Describe) Yes No Effective date ______

2. Are your services local, national or Local only international? (Check [X] only ONE.) National, some states National, all states National, all states + international

3. Do you have educational material which Yes, available at no additional cost informs enrollees regarding your UM Yes, available with an added cost of $ services & procedures? (Check [X] only _____ ONE.) No, but can develop at no added cost No, but can develop with an added cost of $ _____ No, not available

B. PRE-SERVICE REVIEW (PRE-CERTIFICATION)

4. Do you have a standard pre-certification Yes No requirement for any of the following (Y / N)?

 If Yes, check [X] all applicable to your Hospitalizations program: Outpatient Surgery Specified Diagnostic Procedures Durable Medical Equipment Corrective Appliances / Prosthetics Skilled Nursing Facility Home Health Care Musculoskeletal Services (e.g., chiropractic) Medical Services (e.g., physical therapy)

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc Inpatient Mental Health / Substance Abuse Outpatient Mental Health/Substance Abuse Other ______

5. Indicate the primary method for HCIA/PAS book for ______determining the appropriate length of (Region / Percentile / Year) stay for a hospital admission. (Check [X] Internally developed written only ONE.) LOS table LOS not pre-assigned Other purchased written LOS table (specify) Other

6. Indicate the category of staff who can Clerical make final disapproval for a preservice LPN / LVN request. RN Physician

C. CONCURRENT/CONTINUED STAY REVIEW

7. Does your firm perform concurrent Yes No review services?

D. CASE MANAGEMENT

8. Does your firm have an ACTIVE case Yes No management program?

9. During case management, does your Yes staff negotiate fee reductions with No providers and vendors? (Check [X] only No, but will to develop for this ONE.) client

10. Describe your catastrophic case management program.

 What reports will be provided?

 And with what frequency?

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc XV. DISEASE MANAGEMENT QUESTIONNAIRE (OPTIONAL)

1. Does your organization offer disease Yes No management programs?

2. Is your DM program developed internally, or provided through an outside vendor?

 If an outside vendor, indicate the name(s) of the firm(s).

3. Describe any in- or out-of-state Centers of Excellence required by your plans.

 If you are quoting stop loss, does your stop-loss insurance require use of these facilities?

4. Indicate the types and levels of URAC accreditation you currently have specific NCQA to your DM programs. (Check [X] those Other that apply.)

 If none, are steps being taken to Yes No obtain accreditation?

5. What standard diagnoses / chronic conditions are covered?

 What optional diagnoses / conditions can be covered?

6. How will outcomes be reported for each proposed intervention?

7. Describe how your program would interface with the Plan's:

 Prescription drug benefits

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc  Mental health benefits

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc 8. Describe your reporting capabilities and methodology.

9. Are the following reports available to the client? If so, indicate frequency next to your response.

 Cost savings reports Yes No

Frequency______

 Utilization reports Yes No

Frequency______

10. How do you measure the cost- effectiveness of your program?

 Are you willing to guarantee ROI? If so, elaborate.

11. Are the costs included in your quotation? Yes No

 If not, what are the additional costs?

12. List five (5) of your major clients, including size of programs and services used.

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc XVI. STOP LOSS QUESTIONNAIRE

VENDORS MUST COMPLETE THIS SECTION. PROVIDE RESPONSES FOR ONE STOP LOSS CARRIER ONLY.

A. GENERAL INFORMATION

1. How long has your organization been in business? Year established: ______

2. Has your company done business under other Yes No names? If yes, please provide historical background information. Identify any interests your organization may have with associated vendors (TPA, brokerage, managed care firms, etc.) which may be perceived as a conflict of interest.

3. Have you ever been suspended from writing this Yes No line of coverage? If yes, please describe.

4. Is your organization licensed to do business in Yes No South Dakota?

5. What percentage of the risk does your company ______% assume?

 If less than 100%, please identify additional reinsurer(s) and the respective percentage of assumed liability.

 In what month do your reinsurance treat(ies) renew?

6. How many excess loss clients do you currently ______have?

 How much annualized premium do these clients represent?

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc 7. Please provide your current A.M. Best, Moodys, AM Best: ______Standard & Poors and Duff & Phelps ratings. Moodys: ______S & P: ______D & P: ______

8. If your business is underwritten through a trust, Provided in Section ______. please provide a copy of the trust agreement.

9. Please describe your disclosure process for pre- sale and at renewal (if different).

10. Please provide a copy of your reinsurance Provided in Section ______. contract and any amendments.

 When was the enclosed contract adopted?

 Please provide a copy of your disclosure Provided in Section ______. statements.

B. PROPOSAL

11. What industries (if any) does your company consider to be “preferred”? Please list.

12. What percentage discount / credit is applied to your “first year” individual and aggregate pricing?

13. How long are your individual and aggregate excess loss rates guaranteed?

 Are you willing to guarantee these rates for a Yes No period longer than twelve months?

 If yes, under what conditions?

14. Is your organization’s excess loss contract Yes No guaranteed renewable? Page 58 of 87

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc  If no, describe your determination and notification methods.

15. When do you consider claims experience to be fully credible? Please describe.

16. Coverage is based on a no-loss / no-gain full Agree Disagree transfer of coverage basis. If disagree, please explain.

17. Gallagher Benefit Services desires firm rates at Agree Disagree least 30 days (90 days for public entity clients when necessary) prior to sale. If disagree, please explain.

18. Gallagher Benefit Services considers coverage to Agree Disagree be “bound” when the new carrier is in receipt of the binder check or first month’s premium payment and executed application. Do you agree with this statement? If disagree, please explain.

19. Once firm rates are presented and coverage is Agree Disagree bound, your organization cannot impose a modification of rates or factors mid-year. If disagree, explain.

20. Confirm that your individual and aggregate coverage(s) can include the following benefits: Individual (ISL) Aggregate (ASL)  Medical Yes No Yes No  Prescription Drug Yes No Yes No

21. Do you laser individuals at policy inception? Yes No

 Do you laser individuals at renewal? Yes No

 If yes, indicate whether this applies only to those lasered under the initial contract terms, or if potentially large claimants are reviewed annually.

 As an alternative, are all groups given the Yes No

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc opportunity to instead choose a premium increase?

22. Are you able to propose a terminal liability option Yes No for a group that may, at some point in the future, choose to convert to a fully-insured arrangement?

 What is the cost to include this option?

 Is this option available at initial policy issue Yes No and also at renewal?

23. Does your Aggregate contract impose an annual Yes No maximum claim liability amount?

 If yes, identify the amount.

24. Can your organization offer the individual deductible Standard on a standard, aggregating and/or family basis? Aggregating Family Other ______

25. Fully describe all commissions, overrides, contingencies and service fees to be paid for stop loss insurance. NOTE: The Client may audit for compliance.

26. What percentage, if any, of annual paid claims ______% ______N/A applies to initial run-in limitations on your aggregate contract?

 Will your organization waive run-in limitations? Yes No

 If yes, at what cost / percentage?

27. Do you offer pricing consideration when multiple Yes No lines of coverage are purchased?

 If so, please provide details.

C. RENEWAL

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc 28. The client requires preliminary renewal information Yes No from their vendors 90 days in advance of their actual renewal. Is your organization able to comply with this request? If no, explain. (Renewals will be finalized 45 days prior to contract expiration. Renewals are due by 5/1 and must be finalized by 6/15 for an 8/1 expiration date.)

29. What information do you require from the client, their TPA and/or the client’s professional advisor to issue a renewal? Be specific regarding all claim experience and disclosure requirements.

30. We require renewal rates and factors to be Agree Disagree finalized no later than thirty days prior to the date of renewal. If disagree, explain.

31. What contract features are subject to adjustment from preliminary to final renewal?

 Individual Rate(s) Yes No  Aggregate Factor Yes No  Aggregate Rate Yes No

D. CLAIM REIMBURSEMENT

32. What are your proof of claim and timely filing requirements for claim reimbursement requests?

33. Who has final claim decision-making authority with respect to individual and aggregate claims?

34. What is your organization’s average turnaround time for specific and aggregate claims submitted for reimbursement?  Individual  Aggregate

35. Who defines what the reasonable and customary amounts are? Page 61 of 87

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc 36. With respect to Individual and Aggregate claims submitted for reimbursement, please describe any limitations (e.g., minimum dollar amounts).

37. Is the maximum benefit for individual excess loss the Yes No plan’s lifetime maximum amount less the individual deductible amount?

38. Do you offer advance funding or quick pay options Yes No for INDIVIDUAL claims? If so, please provide details including any additional cost, if any.

39. Do you offer advance funding or quick pay options Yes No for AGGREGRATE claims before end of plan year? If so, please provide details, including any additional cost, f any.

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc 40. Explain your organization’s underwriting guidelines for incorporating plan changes.

Must plan changes be approved in writing prior to Yes No implementation?

41. Do you designate a Large Case Management firm Yes No with whom the TPA (or Pre-cert vendor) must coordinate potentially catastrophic cases?

42. Are there any conditions or circumstances (e.g., Yes No diagnosis, procedure, medical services, etc.) that require pre-approval by your case managers? If yes, please list.

43. Is there a Transplant Centers of Excellence Yes No provision in your contract?

If so, is this a voluntary or mandatory program? Yes No Explain the consequences for non-compliance.

44. Are Case Management fees reimbursable to the Yes No client?

Are Case Management fees included in an Yes No individual’s lifetime maximum benefit calculation?

45. Will you allow “non-covered” alternative care, if Yes No approved by your case managers?

46. When do you require notification of an individual _____% of Specific claim? Deductible Amount, or _____

47. How often do you require aggregate claim reporting information?

48. What are your company’s timing requirements Page 63 of 87

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc with respect to notification and claim filing?

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc 49. Does your contract recognize all eligible Yes No employees, dependents, FMLA, retirees and COBRA beneficiaries as defined by the Master Plan Document?

50. Other than the employer’s Plan Document/SPD, Yes No does the contract allow for guidelines found in the employer’s Employee Handbook (e.g. leave of absence policy)?

51. Is there ever a situation in which you would deny a Yes No claim that was a covered benefit in an employer’s Plan Document/SPD you had previously approved?

52. Please identify any restrictions and limitations pertaining to an off-anniversary termination.

53. Please detail the process involved in obtaining coverage for out-of-contract services.

54. If PPO access fees are payable as a percentage of Yes No savings, are the charges in excess of the individual deductible reimbursed?

55. Your contract must waive “Actively at work” Agree Disagree provisions, based upon HIPAA guidelines.

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc 56. Gallagher Benefit Services desires that the employer’s Plan Document/SPD be the controlling document for all claim determinations. If your contract does not rely on the employer’s Plan Document/SPD for claim determination, does your contract include provisions for the following? If no, explain your organization’s position regarding coverage for the listed provision.

a) Work-related exclusions (worker’s Yes No compensation vs. any gainful employment) b) Non-medically necessary charges Yes No c) Experimental procedures, drugs or Yes No treatment d) Biologically-based mental disorders Yes No e) Non-biologically-based mental/nervous, Yes No alcohol and substance abuse f) Administrative, investigative and legal Yes No services, including compensatory & punitive damages g) Charges recoverable by a third-party Yes No (subrogation and/or Medicare) h) Expenses that are incurred as a result of Yes No war i) Expenses that are incurred as a result of an Yes No act of terrorism on domestic and foreign soil j) Expenses incurred while committing Yes No assault/felony k) Charges related to attempted suicide Yes No l) Charges related to hazardous pursuits Yes No m) Please include any other significant provisions which you feel need to be addressed and your organization’s position regarding those provisions.

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc 57. Identify whether your excess loss contract has any N/A, coverage for all limits related to the following provisions: benefits is provided if adequate clarification is provided in the Master Plan Document / SPD

 Late Entrants  Annual Open Enrollment  Section 125-qualified change in status events  Domestic Partner coverage  Transplants (describe any requirements and limitations)  Biologically-based mental disorders  Non-biologically based mental/nervous and/or substance abuse  Alternative therapies (e.g. acupuncture, homeopathic or naturopathic, etc.)  Attempted suicide (whether sane or insane)  Acts of war  Acts of terrorism on domestic and foreign soil  Commission of a felony

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc XVII. PRESCRIPTION DRUG QUESTIONNAIRE

A. ADMINISTRATIVE FUNCTIONS

1. Describe the support team that will handle the account.

2. Thoroughly describe your Customer Service Operations with regard to:

 Staffing

 Hours of operation

 Location

 Standards

 Technology

3. Can you provide a national network of Yes No pharmacies?

4. Describe how out-of-network claims are processed.

5. What Utilization Review programs are included in your proposal?

6. Does your company monitor drug interactions? Yes No

7. Does your company monitor the frequency or Yes No number of prescriptions by individual?

8. Do you have the ability to provide a Yes No

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc coordination of benefit (COB) provision?

 Is there an added cost?

9. Do you agree to provide the client and its Yes No actuary all claims and eligibility data needed for it to comply with GASB 45?

B. RETAIL PHARMACY NETWORK

10 Are networks of varying size available? Please . clearly describe differences in participating pharmacies, differences in discount arrangements, and estimated overall impact on drug spending.

11 Submit a current listing of participating . pharmacies in South Dakota.

12 Would your organization be willing to contract . with additional pharmacies if there are geographic locations where participants live but which do not have access to one of your pharmacies?

C. FORMULARIES & REBATES

13 Are the formularies based on the lowest cost . prescriptions available?

14 Do all drug manufacturers whose products are . included in your formulary provide your network with rebates?

 If so, how are the rebates shared with the plan sponsor?

 If so, are the rebate dollars paid to the plan sponsor or are credits given prospectively?

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc 15 How often is the formulary printed and . distributed to clients?

 How often do the drugs on the formulary change?

 Is your formulary available on the Internet?

16 Will you agree to remit or credit back to . premium 100% of manufacturers’ rebates and incentives of any kind to the employer?

 If not, what percentage?

 How often?

17 If a mail order program is offered in conjunction Yes No . with your retail program, does the formulary rebate program apply to the mail order program?

18 Do you guarantee that ingredient cost charges Yes No . made by network pharmacies will be based on the lesser of the discount offered, actual retail paid, MAC price or your actual acquisition costs?

 If not, explain.

19 Does the PBM receive rebates or other forms of Yes No . reimbursement from the manufacturers that is not disclosed or shared with the client?

D. MAIL ORDER PRESCRIPTION DRUG PROGRAM

20 Do you have your own mail order prescription Yes No . drug program? If not, skip to following question.

 If so, is it fully integrated with your retail network?  Where is your mail order pharmacy located?

21 Do you subcontract with an outside mail order Yes No Page 70 of 87

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc vendor?

 If so, which mail order vendor do you use?

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc 22 Do you have a toll-free telephone number that Yes No . participants can use?

 When is your telephone service available?

 Can they speak directly with a pharmacist?

23 Is there an internet pharmacy available through Yes No . your PBM?

 If so, please describe.

E. PHARMACY CONTRACTING

24 Do you maintain the same pricing contracts for Yes No . all network pharmacies?

 If not, explain.

25 Please respond to the following questions . regarding your MAC program.

 Is it a private labeled program?

 How are non-MAC multi-source categories priced?  Does your MAC apply to mail order?

 Is your MAC priced the same as FUL MAC, above FUL MAC or below FUL MAC?

 Do you repackage generics, or allow your pharmacies (including mail order) to repackage and bill at a discounted AWP?

F. ELIGIBILITY / MAINTENANCE SERVICES

26 Is there an additional / separate ID card Yes No . required for prescription drug coverage?

 Are dependents listed by name on the pharmacy card?

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc 27 Do you charge a fee for card preparation? Yes No .

28 Can you do a combination medical / Rx card? Yes No .  Is there any additional charge for this?

29 Can you put the plan sponsor name and logo on Yes No . the Rx card

 Is there any additional charge for this?

30 What is the charge for replacement cards? .

G. DRUG UTILIZATION REVIEW

31 Indicate which of the following are included at . no cost in your Drug Utilization Review (DUR) programs:

 Drug to drug interactions  Duplicate therapy  Refill too soon  Duplicate claims  Excessive dosage  Drug to allergy interactions

H. PRICING

32 Does your organization collect any other Yes No . payment from pharmaceutical manufacturers for any type of formulary management, therapeutic interchange or similarly “named” practices?

 If so, how will these dollars be reported and shared?

33 Are you willing to undergo or perform a 100% Yes No . retrospective electronic audit to confirm guarantees?

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc  Additional costs?

34 Does/do your AWP pricing/guarantees include Yes No . $0 claims or other similar transactions?

35 Are all generics dispensed on a MAC basis? Yes No .  If not, what is your historical percentage?

36 Do you provide pharmacists with incentives to Yes No . dispense generics?

 If so, please describe.

37 Are you willing to guarantee maximum Yes No . dispensing fees (retail and mail order)?  If so, at what levels?

 How are results verified?

3 Are you willing to guarantee minimum AWP Yes No 8. discounts (retail and mail order)?  If so, at what levels?

39 Are you willing to guarantee maximum Yes No . administration fees (retail and mail order)?  If so, at what levels?

I. REPORTING

40 Describe the claim and utilization reports that . will be made available as part of your quoted fee. Provide samples of all.

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc XVIII. MEDICAL NETWORK ANALYSIS SECTION (FOR SELF-FUNDED MEDICAL PLANS)

VENDORS MUST COMPLETE ALL REQUESTED EXHIBITS IN THIS SECTION. NOTE: SOME OF THE WORKBOOKS CONTAIN MULTIPLE WORKSHEETS. ALL WORKSHEETS MUST BE COMPLETED.

NETWORK ACCESS (PHYSICIANS AND HOSPITALS)

Complete Exhibit 1 (Excel File: EXHIBIT 1-Medical-Network Accessibility.xls).

MAJOR HOSPITAL COMPARISON

Complete Exhibit 2 (Excel File: EXHIBIT 2 – Medical-Major Hospitals.xls).

HOSPITAL CONTRACTUAL PAYMENT FORM

Complete Exhibit 3 (Excel File: EXHIBIT 3 – Medical-Hospital Contracts.xls). NOTE: Submit this exhibit to Gallagher Benefit Services only; do not submit to the School District.

GEO-ACCESS REQUEST

Provide a geo access as outlined in Exhibit 4 (Excel File: EXHIBIT 4-Medical- Geo Access.xls).

NETWORK ANALYSIS - PROFESSIONAL

Complete Exhibit 5 (Excel File: EXHIBIT 5-Medical-Network Analysis Professional.xls) for each location indicated. NOTE: Submit this exhibit to Gallagher Benefit Services only; do not submit to the School District.

DISRUPTION ANALYSIS

Complete Exhibit 6 (Excel File: EXHIBIT 6-Medical-Disruption Analysis.xls).

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc XIX. DENTAL PLAN QUESTIONNAIRE

VENDORS MUST COMPLETE THIS SECTION. A. DENTAL CARE

1. Describe any pre-authorization requirements and the process.

2. Deviations from the specifications:

 For insured proposals. Will your organization underwrite and Yes No administer the benefit program exactly as shown in this material?

 If no, please explain.

 Please list any other items that can be considered deviations from the specifications.

3. How and when do you assume responsibility for orthodontic treatment that is in process on the effective date? Explain.

4. Do you have an extension of benefits Yes No when an employee initiates treatment while covered and completes it after termination of coverage?

 If yes, for Major Restoration _____ Months _____Until work completion

 If yes, for Orthodontia _____ Months _____Until work completion

5. Are the following services covered under the Basic or Major Services Benefit?  Endodontics Basic Major

 Periodontics Basic Major

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc Page 77 of 87

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc B. DENTAL NETWORK

6. With regard to network directories, please respond to the following items. (NOTE: Do NOT include a provider directory with your proposal.)

 Is your directory available on the internet on in a website? Yes No

 If your provider directories are not available online, how frequently are directories distributed?

 How are members, plan sponsors and providers notified of changes?

7. Do you own your provider network, or do you subcontract?

 If you subcontract, please identify network.

8. Are you willing to add providers specifically Yes No requested by our organization?

9. How often are the Dental R & C allowances revised?

1 How often are the Network allowances revised? 0.

1 Do you have differing network provider Yes No 1. arrangements (e.g., “Preferred” vs. “Participating”)? If yes, describe.

1 If you do have different network provider 2. arrangements, please complete the following chart.

Network Discounts Network Discounts Available with Available with plan design NO plan design differentials differentials

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc “Preferred” Provider Yes No Yes No

“Participating” Yes No Yes No Provider

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc 13 How are “Preferred” dentists paid? Discounted fee for service . Fee schedule: describe Other

14 How are “Participating” dentists paid? Discounted fee for service . Fee schedule: describe Other

15 Do the participating dentists have a contractual Yes No . agreement not to “balance bill” the patient?

16 If a participating dentist refers a patient outside the Yes No . network, are benefits paid at the Dental PPO level?

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc XXI. DENTAL NETWORK ANALYSIS

VENDORS MUST COMPLETE ALL REQUESTED EXHIBITS IN THIS SECTION.

NOTE: SOME OF THE WORKBOOKS CONTAIN MULTIPLE WORKSHEETS. ALL WORKSHEETS MUST BE COMPLETED.

NETWORK ACCESSIBILITY

Please complete EXHIBIT 7 (Excel Workbook: EXHIBIT 7-Dental Network Accessibility.xls).

GEO ACCESS

Please complete EXHIBIT 8 (Excel Workbook: EXHIBIT 8-Dental-Geo Access.xls).

DISRUPTION ANALYSIS

Please complete EXHIBIT 9 (Excel Workbook: EXHIBIT 9-Dental-Disruption Analysis.xls).

DENTAL NETWORK ANALYSIS

Please complete EXHIBIT 10 (Excel Workbook: EXHIBIT 10-Dental-Network Analysis.xls).

NOTE: Submit this exhibit to Gallagher Benefit Services only; do not submit to the School District.

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc XXII. BASIC LIFE AND AD&D INSURANCE QUESTIONNAIRE

VENDORS MUST COMPLETE THE FOLLOWING QUESTIONNAIRE.

1. Termination of the master contract Agree Disagree cannot eliminate your liability (waiver of premium) for an employee whose disability occurred prior to termination of the master contract.

2. AD&D coverage must be provided on a Agree Disagree 24-hour basis.

3. The Life benefit must be payable for Agree Disagree death from any cause.

4. Confirm that your company will Agree Disagree transition existing insureds at the insurance amounts currently in place.

 Also confirm that no restrictions will Agree Disagree be applied to these insureds.

5. The AD&D benefit must be payable for Agree Disagree loss resulting from injury for up to a period of 365 days.

6. If there is a death claim, either for an Agree Disagree active employee or dependent and/or previously disabled employee, the current vendor and new vendor will cooperatively work with each other to determine which vendor will be responsible for paying the death claim. This could include circumstances where the employer failed to file waiver of premium paperwork for disabled employees and other such administrative errors by the employer.

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc 7. How is the Life plan rated? Pooled Experience Rated

 If experience rated, is it eligible for Yes No dividends?

8. Indicate the level of credibility assigned to the experience of this group for:

 1st Year

 1st Renewal

9. Provide dependent life coverage as part Agree Disagree of the Basic Life insurance plan?

10 What are your age-related benefit . reductions?

11 Will you provide interest credit from the . date of death to the date a benefit is paid?

 If so, at what rate?

 Is such interest payment charged against the experience of the Plan?

12 Do you provide a living benefit / Yes No . accelerated death benefit?

 What is the benefit percentage?

 What is the minimum benefit amount?  What is the maximum benefit amount?  If available, provide details of the program.

 Is there an impact on the rates?

13 Does your life insurance plan include a Yes No . conversion provision?

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc  If so, what is your conversion charge?  Where and when will these charges appear in your financial accounting?

 Does conversion apply to dependent life coverage (if offered in conjunction with the Basic Life program)? Or, does it apply only to employee coverage?

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc 14 Does your Basic Life insurance plan Yes No . include a portability provision?

 Does portability apply to dependent Dependent Life Employee Only life coverage (if offered in Coverage conjunction with Basic Life program)? Or does it only apply to employee only coverage?  Do you use a separate set of Yes No portability rates for employees / spouses / dependent children that port coverage?

 If a separate set of portability rates is used, do you apply any underwriting criteria to those individuals?

 If so, can you deny coverage or Yes No rate adjust coverage for ported individuals after underwriting?

 How frequently are rates adjusted for individuals with ported coverage?

 Can individuals port the entire Yes No amount of life insurance?

 Is portability linked to a coverage Yes No limit (e.g., must be covered for a minimum of 2 years)? Please provide details.  Do you limit the term of an Yes No individual’s coverage under a ported contract (e.g., 3 years, to a certain age, etc.)? Please provide details.

 Should the master contract Yes No terminate, are individuals with ported coverage affected (i.e., would their coverage terminate)? Please provide details.

 Does claims experience on ported Yes No coverage factor in the overall claims experience for the group’s active employees and dependents?

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc All existing coverage amounts for 15 Agree Disagree employees and spouses should be . grandfathered, regardless of when the individual was underwritten.

16 Your proposal should provide a complete . list of your AD&D benefits.

17 Also, complete the table below . indicating if your AD&D plan provides the benefit and, if so, what the benefit is:

 Seat belt benefit  Airbag benefit  Hemiplegia  Paraplegia  Quadriplegia  Coma  Repatriation  Others

18 What is your formula for establishing . premium waiver reserves?  What interest do you allow on these reserves?

 How is it credited?

19 Provide a full explanation of how the . waiver of premium provision works.

20 What margin level have you included in . the life insurance rates?

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc XIII. PROPOSED COST EXHIBITS

VENDORS MUST COMPLETE ALL EXHIBITS (AS APPLICABLE TO THE COVERAGES QUOTED) IN THIS SECTION.

NOTE: THE WORKBOOKS CONTAIN MULTIPLE WORKSHEETS. ALL WORKSHEETS MUST BE COMPLETED.

 Medical. Complete Exhibit 11 (Excel File: EXHIBIT 11-Proposed Costs- Medical.xls).

 Dental. Complete Exhibit 12 (Excel File: EXHIBIT 12-Proposed Costs- Dental.xls).

 Life and AD&D. Complete Exhibit 13 (Excel File: EXHIBIT 13-Proposed Costs-Life.xls).

Please note that the workbooks contain multiple worksheets.

XIIV. SIGNATURE PAGE

VENDORS MUST COMPLETE THE SIGNATURE PAGE.

Complete and sign the Signature Page contained in EXHIBIT 14 (Word Document EXHIBIT 14-Signature Page.doc).

D:\Docs\2017-12-16\083289a527293bafe978de353bb0b716.doc